At the Scrub Sink: Minimally Invasive Sacrocolopexy.

I use delayed absorbable monofilament suture to sew the mesh to the vagina. A permanent material is not needed as the mesh will heal into the vagina independent of suture type. Permanent sutures also can erode into the vagina and may require excision. Thus, I recommend avoiding anything permanent beyond the mesh. Make sure the mesh is as flat as possible when sewing it into place to avoid creating a mesh exposure. The mesh can be secured using continuous or interrupted sutures. When attaching to the sacrum, I typically use a tack device as it helps to keep the mesh flat. Although sutures are certainly acceptable, they tend to bunch and wrinkle the mesh when they are tied down. Finally, the mesh bridge is the site most prone to failure. Therefore, when using an ultralight Y mesh, I recommend folding the stem in half along the longitudinal plane, so the stem has twice the amount of mesh in the bridge to the sacrum to decrease risk of failure.

I always perform a cystoscopy at the end of the case to confirm absence of injury to the bladder and free flow of urine from the ureteral orifices. Similarly, I perform a rectal examination to confirm that absence of sutures and no evidence of injury.

The sacrum can present challenges to the surgeon including a low descending left common iliac vein or right common iliac artery, distortion due to bony abnormalities, and difficult access from adhesions or excess fat. For this reason, I recommend starting with the sacral dissection. It does not make sense to place your mesh on the vagina only to discover that you are not able to complete the sacral dissection. For the dissection, I recommend placing the patient in steep Trendelenberg before retracting the sigmoid laterally with either a robotic arm, laparoscopic grasper, or a purse string suture that is placed through the sigmoid epiploica and gently pulled through a lateral port. Before entry into the peritoneum overlying the sacrum, note the position of the left common iliac veins and arteries, the ureter, and the sigmoid. Entry into the peritoneum should be at the thinnest portion, especially in obese patients in whom there is a large fat burden. This point is typically immediately medial to the sigmoid colon. Dissection should be hemostatic as bleeding will distort visualization of normal surgical planes, and blood that does appear in the dissection can be cleaned with an inserted sponge to minimize plane distortion. When exposing the longitudinal ligament, I prefer to seal the middle sacral vessels with a bipolar energy device to avoid bleeding during mesh placement. The exposed area should be large enough to afford mesh attachment with good visualization of the surrounding structures and to allow the mesh to lay flat.

In women with a prior hysterectomy and/or a prior native tissue repair or a history of endometriosis or other distorting adhesive disease, defining the position of the bladder and rectum relative to the vagina can be challenging. I recommend keeping the Foley accessible and filling the bladder with water until it is completely distended to define its borders. This can be repeated multiple times during the dissection to confirm anatomy and assess for injury. I also recommend using a rectal probe to define the position of the rectum. Both the bladder and the rectum can be scarred from prior colporraphies, which can obliterate normal tissue planes.

Current evidence shows that deformations in mesh (pore collapse and wrinkling) that occur with tensioning and loading lead to mesh complications (encapsulation and exposure). Meshes with square pores have been shown to be stable when exposed to loads mimicking sacrocolpopexy ex vivo and in animal models of sacrocolpopexy in vivo. For this reason, I always choose a square pored mesh. Some surgeons may be reluctant to use ultralight weight meshes as retrospective data suggest that they may fail more than their heavier-weight counterparts, particularly in the context of robotic sacrocolpopexy (see below pearl regarding preventing failure of an ultra-lightweight mesh).

A patient with a history of abnormal Papanicolaou smears or elevated risk for cervical malignancy (such as HIV or high-risk HPV infection) or abnormal uterine bleeding concerning for or increased risk of endometrial hyperplasia/malignancy may choose to have her uterus completely removed. Those without a history of cervical disease may benefit by keeping the cervix in place, as this helps to reduce mesh wrinkling and is associated with lower rates of mesh exposure.

For the anterior and posterior vaginal dissections, I place a large Briesky retractor or equivalent into the vagina to maintain the vagina in a flat configuration during the dissection. If a supracervical hysterectomy is performed, I place the retractor in the anterior or posterior fornix. The retractor should be wide enough to span the width of the mesh (ie, 4–5 cm). Posteriorly, I aim to dissect the rectum off the vagina to within 3 cm of the perineal body. Anteriorly, I dissect the bladder off the vagina to just proximal to the trigone. I remind my trainees to look for the adventitial loose connective tissue plane. When in that plane of dissection, there is a low likelihood of injury to the bladder, rectum, or vagina. Maintaining hemostasis will improve visualization of tissue planes as well as mitigate the inflammatory response and improve healing.

I recommend using a retractor in the posterior fornix to bring the vagina up toward the sacrum. The posterior vagina is often slightly longer than the anterior vagina, so using it to determine the amount of tension reduces the risk of overtensioning the anterior vagina and causing occult incontinence. Once the vagina is brought up in position along the longitudinal plane of the sacrum, the mesh is secured in place. The retractor is then gently removed from the vagina.

I favor retroperitonealizing the mesh as a precautionary step that reduces the risk of future complications including bowel adhering to the mesh, which would complicate a future mesh removal (if needed) or cause a bowel obstruction. Retroperitonealization also prevents bowel from becoming entrapped under the mesh bridge to the sacrum, which can lead to pain and obstruction.